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Provider enrollment is crucial for health plans to ensure that members have access to a full range of services. Credentialing verifies a clinician’s training and licensing. Enrollment establishes the technical connection between the provider and the plan. The processes can be complex and time-consuming, but partnering with dedicated enrollment experts – like UHIN – can help streamline the onboarding experience and accelerate success in a highly competitive marketplace.

Why Enrollment Matters

Health plans are constantly looking for better ways to serve the insured, from developing innovative wellness benefits to making it easier to access high-quality, affordable care in the community.

Provider network development is a huge component of this quest for continuous improvement. Contracting with the right mix of providers – and enough of them – ensures that members can get a full range of services within an acceptable time frame.

Building this ecosystem isn’t always easy, especially when it comes to the nuts and bolts of bringing clinicians on board. Provider credentialing and provider enrollment are equally critical, yet they can often cause confusion and problems on both sides of the plan-provider relationship.

In fact, providers not being registered/credentialed with a payer is the #1 reason for denials. The #2 reason for denials: the provider did not complete the payer-required process for enrollment.

Both steps – credentialing and enrollment – are crucial. However, even the fundamental differences between the two activities aren’t always clear, especially because they bump up against each other during onboarding. It’s important to understand what’s involved in each process, how they work, and why finding the right partner matters so much to health plans as they grow and mature.

What is Provider Credentialing?

Provider credentialing is the act of verifying that a clinician has the correct training and licensing to practice in their area of expertise. It’s similar to an extensive background check. The process starts after a provider submits a request to work with a practice, health system, or health plan. Collecting this extensive dataset can take up to three months or longer.

While UHIN does not currently support the credentialing process, certain industry applications are in place, including the CAQH credentialing application. Until the credentialing process is complete, a provider cannot finish the rest of the enrollment process with a health plan. This is especially important for 98 percent of providers in the US who participate in Medicare and Medicare Advantage. In addition, nearly every health plan, including Medicare, requires EDI enrollment in order to start getting reimbursed for services.

What is Provider Enrollment?

Once a provider is officially welcomed into the network, the majority of health plans will require them to complete Electronic Data Interchange (EDI) enrollment, which is the technical connection between the provider and the plan. EDI enrollment allows providers to submit electronic claims to the plan and receive remittance for their services.

Electronic claims submission is nearly universal in the medical industry, according to the latest CAQH index report. In 2022, 97 percent of claims submissions transactions occurred electronically, giving both providers and health plans a strong motivation to ensure they are appropriately connected.

Unfortunately, neither the administrative nor the EDI enrollment processes are standardized across different health plans. This forces providers to juggle many different requirements and documentation requests for each individual payer. The complexity of managing requests from a slew of disparate plans and providers can lead to mistakes and omissions that extend the timeline.

Even more information may be required during EDI enrollment than credentialing. This can take an additional four to six weeks (or longer) on top of the credentialing timeframe. This is especially true if extensive contract negotiations are necessary or IT challenges get in the way.

In addition, smaller provider groups often do not have enough people-power to devote exclusively to enrollment, making it even more difficult for plans and providers to work together effectively.

UHIN’s Enrollment Team provides detailed next steps for enrollment based on each specific payer and transaction type for each case. Additionally, we provide defined next steps to move forward with enrollment, based on the payer requirements. UHIN can be reached at enrollment@uhin.org and we will be happy to provide enrollment direction, advice and helpful support through the EDI enrollment process.

How Can Health Plans Streamline Enrollment Processes?

Just like many other areas of the healthcare ecosystem, provider EDI enrollment can significantly benefit from digitization and strong partnerships with expert teams. The widespread lack of standardized processes means plans and providers have to consider each request as a one-off, which can take a great deal of time and effort to parse through without some help.

Charting a Course for Success

When working with providers, health plans should offer clear and detailed instructions on the information needed and the deadlines for delivering it.

Plans should assess their needs by charting out their existing enrollment workflow and identifying any bottlenecks that lead to lag time. Often, these pain points are related to delays in collecting information from providers and internal delays in processing paperwork once received. The result of these delays are wild swings in average completion time for provider onboarding, which creates unpredictability on both sides of the relationship.

Finding the Right Support

On the internal front, plans should seek out enrollment partners that can field provider requests on behalf of the payer, taking the task off the shoulders of health plan staff. It should take a specialist enrollment team less than one business day to process a request once all of the information is received. There may be additional waiting time depending on the unique payer requirements.

Health plans and providers should make sure they are working with a dedicated enrollment team that can take deep dives into problem-solving when unique technical or administrative challenges arise, such as a technology enhancement that can lead to the need for a process rewrite.

An experienced partner, such as UHIN, offers an expert enrollment team to help navigate the complicated enrollment process. Although we do not currently provide credentialing support, we have a proven history in expediting and accurately guiding providers through the enrollment process. Our enrollment team is based in the US and delivers in-depth knowledge and support to make the enrollment process as frictionless as possible. We can handle any questions you may have in this complicated and critical process.

Partnering with the Right EDI Enrollment Experts

Enrollment involves complex activities with many moving pieces. Getting them right is vital for the success of health plans and provider groups. By understanding the nuances of the process, plans and providers can start to tackle the pinch points that make network development so challenging. Plans that enlist the help of dedicated partners to take on key tasks, such as enrollment, have a better chance of creating a smoother onboarding experience and accelerating their success in a highly competitive marketplace.

UHIN’s enrollment team offers years of experience helping providers through the enrollment process. We provide direct support and in-depth knowledge to expedite the enrollment process and get providers over the finish line no matter how complex or unique the process may be.

Are you a current provider with a UHIN account and interested in learning more about enrollment? Contact enrollment@uhin.org or customer service at 877-693-3071.

If you’re new to UHIN, click below and tell us how we can help streamline EDI enrollment onboarding and relieve burdens for your health plan!

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Clearinghouses are more than just utilities for moving claims from provider to payer. They are integral to improved healthcare interoperability and the quest to extract valuable insights from clinical and administrative data.

How Clearinghouses Help to Enable Interoperability

When talking about interoperability in healthcare, clearinghouses aren’t always the first thing that comes to mind. For many years, the conversation has been much more focused on the exchange of purely clinical data from one provider to another – a challenge that is still only partially solved even after decades of hard work.

While clinical data exchange is certainly vital to success for patients, health plans, and providers, it’s just the tip of the interoperability iceberg. Accurate claims data is equally important for making informed, proactive decisions about patient care.

Claims data doesn’t just offer deep insights into everything from overall provider performance patterns and to an individual’s ability to engage with their care plan. It’s also essential for the day-to-day business of being a payer: reimbursing providers for the wide variety of services aimed at improving member health.

Clearinghouses are the technology that makes this all possible. By coordinating the secure flow of claims information between providers and health plans, clearinghouses quietly and steadily keep the $4.3 trillion healthcare industry humming along.

It’s easy to look past this type of “middleware” solution, especially when it works well enough to avoid causing any major issues. But skipping over clearinghouses during the interoperability discussion would be a mistake, especially as payers and providers start to engage with increasingly complex, unstandardized data sets and new types of clinical and financial partners in a more patient-centered, value-based environment.

It’s time to take a closer look at the clearinghouse as a fundamental enabler of trusted interoperability between trading partners and ensure that both payers and providers are maximizing the value of what these important platforms can do.

The Crucial Role of Clearinghouses in Healthcare Operations

Every year, healthcare providers submit hundreds of millions of claims for patient services to thousands of health plans across the nation.

Just building the electronic pipelines to shuffle all this data back and forth each day is a monumental task. Making sure that the information is accepted and processed in a standardized manner, correctly integrated into a health plan’s internal reimbursement systems, and returned to the provider in a timely manner with the right payment – or a clear explanation for denial – is even more challenging.

Clearinghouses work in conjunction with electronic billing software to handle these processes digitally, proactively identifying common data integrity issues that may result in a denial or delay. Once a provider generates a claim using the standard 837 claim format, the clearinghouse accepts the file, scours it for any obvious errors, and sends it on to the correct health plan if it passes all the checks.

The plan then conducts further analysis for clinical and administrative suitability of the claim and makes a decision on whether to reimburse as requested, deny outright, or ask for clarification.

The more sophisticated and trustworthy the clearinghouse, the less work has to be done on each side of the partnership. Robust clearinghouses with more automation, advanced analytics capabilities, and a trusted position within the health IT community are associated with lower overall denial rates and higher first-pass success rates, which is good for providers, as well as reduced administrative burdens on the payer side.

The American Medical Association estimates that electronic clearinghouses can reduce the cost of claims processing by approximately 60 percent compared to similar paper-based workflows, freeing up time and capital to devote to other clinical or operational priorities.

According to CAQH, transitioning to fully electronic transactions could save the industry up to $25 billion per year, or 41 percent of annual spend in 2022.

Using Clearinghouses to Create a Network of Networks for Better Claims Data Exchange

A single clearinghouse cannot work in isolation, because health plans don’t just receive claims from their established, contracted in-network providers. They also get claims from an untold number of out of network clinicians from anywhere in the country.

This can be challenging on several levels. First, reimbursement rates and requirements are different for these partners. Second, out-of-network providers may not be familiar with the correct formatting and data requirements necessary to get their claims adjudicated quickly. And third, without being directly connected to the prospective payer’s proprietary clearinghouse, these providers must simply trust that hitting “send” on their claim form will result in getting that information where it needs to go.

This is where the right clearinghouse solution can take interoperability to the next level. Clearinghouse vendors must work with their peers, trading partners, and competitors to ensure that all claims, no matter their origin, are routed to the appropriate recipient with as few gaps and errors as possible.

Data standards like ASC X12 Version 5010 make it possible for clearinghouses to assemble into “networks of networks” and make certain that any provider can reach any payer whenever necessary.

Fortunately, the ASC X12 standard is well established in the electronic data exchange community, and claims are typically highly structured documents with relatively few unknowns, making it easier for clearinghouses to engage in the type of interoperability that is often so elusive in the clinical data ecosystem.

Trust as the Bedrock of Interoperability Between Payers and Providers

With trillions of dollars and huge volumes of sensitive clinical data shooting across the claims superhighways at any given moment, it’s essential that all parties involved have full and complete trust in their clearinghouses.

Choosing a clearinghouse with a strong reputation for security, service, experience, and responsiveness can turn an oft-overlooked piece of the interoperability puzzle into a valuable and proactive partner for improving clinical care and administrative efficiency.

A prospective clearinghouse solution provider should be able to demonstrate its mature and wide-reaching connections with peers across the industry to foster seamless interoperability for both in- and out-of-network claims. Platforms should also include process enhancements such as tools to generate cleaner claims, timely provider notifications at key steps in the process, and helpful resources to address any provider questions or problems that arise before or during claims submission.

With a trusted and collaborative clearinghouse, health plans and providers can work together more efficiently and effectively to accomplish their daily tasks while moving into the optimal position to take advantage of everything that rich, robust claims data has to offer.

Clearinghouses shouldn’t just feel like part of the furniture. Instead, they should become an active and integrated part of a health plan’s larger interoperability goals. By simplifying and streamlining the claims submission process, clearinghouses don’t just save time and money for payers. They can also unlock the full potential of claims data for broader financial and clinical analytics purposes, such as provider performance monitoring, population health management, and other high-priority value-based care activities.

Visit our Clearinghouse page to learn more.

Author: UHIN

Provider Credentialing and Provider Enrollment: What’s the Difference and Why Does it Matter?